Monthly Archives: August 2015

I arrived at Highland at 7am and was promptly greeted by a lecture on proper surgical techniques when dealing with neck wounds. The physicians discussed the pros and cons of different evaluative procedures for about 45 minutes, and then wrapped up the meeting. During the chaos, I managed to fall in with the surgical trauma team, led by Dr. Sadeghi and Chief Resident Dr. Parmar, who had an unusual amount of scheduled surgery that day (or so I was told!).

Our first stop was a resident break room, where Dr. Parmar updated me and the two trauma NPs on the status of his patients. I was surprised to learn that he was currently working with around 20 patients. All I could think was “where does he find the time?” After finishing the review, we began rounding. The first patient we saw was an older man who had fallen while seeing a movie with his girlfriend. Upon further prodding it turned out that the movie was 50 Shades of Grey, which got a good laugh out of the team. We then rounded to another patient that was scheduled for surgery later in the day. Most of the tissue in his butt had become necrotic and needed to be removed.

The team and I then went to another break room where Dr. Parmar and one of the NPs looked at CT scans of another patient. They showed me what they were looking for in the images, and constantly asked me if I had any questions. It was inspiring that the team had the energy and personalities to be so welcoming to me, even though I knew that I was essentially just a mild inconvenience to them. After reading the CTs, Dr. Parmar sent to me to assist one of the NPs in pulling a chest tube from a patient who had suffered from a collapsed lung earlier in the day. The NP first showed me the initial x-ray of the collapsed lung, followed by the healed lung, and then we were off. We chatted with the patient briefly before the NP explained to me the correct technique to remove the tube, which is to yank it out as fast as you can!

Once the NP and I met back up with Dr. Parmar, it was time for surgery. They were to be performing a colostomy reversal on a patient that had been a shooting victim months prior. A colostomy is a procedure where the intestines are cut, and both ends are fed to the outside of the belly. This allows bowel movements to be routed away from an injury in the intestines that are further down in the system. In this procedure, Dr. Sadeghi and Dr. Parmar were to reattach the two ends of the intestines. I watched the team scrub up and then we all entered the room.

As the patient went under there was a slight hiccup. The machines were reading a double pulse, and the anesthesiologist was frantically trying to remedy the situation before it became clear what the problem was. Finally, a new EKG was brought in that read normal rhythms and pulse was brought in, and the procedure continued.

First Dr. Parmar sewed up the two stomas, and then the cutting began. The intestines are normally held behind layers of skin, fat, muscle, and a layer of connective tissue called the fascia. Since the two ends of the intestines had been routed through these layers for months, the tissue had healed in place. This meant that the team had to cut the two ends of the intestines away from all the layers before they could be safely reattached and then placed behind the fascia. For around two hours the doctors and NPs slowly cut through the surrounding tissue, making sure not to nick either the intestine or the tissue that delivered blood to the intestine.

The last hour was dedicated to reattaching the two ends of the intestines and then placing them back in the fascia. I couldn’t exactly tell how they were reattaching the ends, but it was done through multiple rounds of stapling. The closure of the wound was quite interesting. They had removed a fair amount of skin during the procedure, so I was wondering how they would close up the wound. It turns out they didn’t! Dr. Parmar just ran surgical thread through the circumference of the wound and then tightened it like the cinching of a small coin purse. Even after this, there was an open wound left that was about 2 inches in diameter. Dr. Sadeghi noted that this technique heals extremely quickly.

After surgery wrapped up, Dr. Parmar and I went to the trauma bay in the ED where a patient had been brought in for severe head trauma. We looked at the CT scan together and Dr. Parmar again walked me through what we were looking for, and what we would see if things were bad. The patient was in good shape, so we headed back to the resident break room. I soon learned that the necrotic tissue removal that I had looked forward to had been put off until the next day, so I thanked the team for an amazing day and I went home after an amazing 10-hour shift!

When I arrived in the surgery wing last Friday for the 7AM lecture, I saw only the residents sitting at the table. They mentioned how Dr. Harken would not be in this morning, so after signing in, I went straight to the 5th floor. I was able to get some homework done before the first surgery, which was a tonsillectomy. The surgeon for this case was Dr. McDonald. The patient was in his late twenties or early thirties. The procedure began with a student inserting a ventilator tube into the patient under the guidance of a senior doctor. They used a laparoscopic camera in order to ensure the proper positioning of the tube. After this, the staff did a few more preparatory procedures (e.g. repositioning the patient) before the operation began. First, the tonsils appeared to be clipped in place before being removed by a pair of surgical scissors. A sickle-shaped instrument was also inserted into the patient’s mouth and may have been used to excise the tonsils. Finally, after the left and right tonsils were removed, the surgeon inserted a heating tool into the patient’s mouth, possibly to seal the cut blood vessels. Overall, the procedure was difficult to observe because it was entirely in the patient’s mouth and was not projected onto any screen like a laparoscopic operation. The operation was also brief, lasting only an hour. After it was completed, I went to the break room for a few minutes before heading to my next surgery.

The next operation I watched was on a left tibia plateau fracture. The surgeon on this case was Dr. Robert Hoffman. The operation was well underway when I entered the OR, but the staff brought me up to speed. The circulating nurse, Wendy, told me that the patient had been in a “pedestrian versus automobile” incident. The patient had his left leg propped up; there was a rectangular opening that started on the left side of his knee and went down to his upper shin. The team had already inserted several K-wires into the patient’s knee, which was visualized via X-ray. The K-wires were adjusted until they crossed in the left side of the left knee. A perforated, rectangular metal plate was then inserted into the leg, covering the left side of the knee down to the upper part of the shin. According to the circulator, the cartilage was damaged and the goal of the operation was to bring the upper and lower parts of the leg back together. The metal plate was needed to set the tibia back in place since it had been shattered into many small pieces by the incident. To conclude the operation, multiple screws were inserted into the knee (there were four horizontally placed screws and two that formed a cross at the knee). The placement of the screws were then checked with X-ray. Dr. Hoffman rinsed the opening with saline before asking the residents to close the wound. As I watched them suture the wound shut, another doctor came up from behind me and took my notebook. I was caught by surprise as he read through my notes out loud and slightly embarrassed by my simplistic observations. However, I quickly realized that the doctor was being tongue-in-cheek, but he nevertheless quizzed me on what had happened during the operation. After failing to give a satisfactory answer to a question on cartilage, the doctor invited me over to the OR next door, where a total knee replacement surgery was about to begin.

I found out that the doctor who invited me into his OR was Dr. Krosin. He was personable, had a good sense of humor and he was very inclusive during the operation. He told me that the patient coming in had arthritis in her left knee, which damaged the cartilage to point where she needed a total knee replacement. As a result of the operation being a total joint replacement, a sign saying “total joint no entry” was placed on the OR doors. Dr. Krosin explained this as an extra precaution; while all operations needed to be safeguarded against possible infection, the consequences of a joint being infected were considerably more dire than other cases. Nevertheless, Dr. Krosin said that I was free to leave whenever I needed to. The operation itself was incredibly dramatic. The speed and forcefulness with which the surgeons operated (e.g. their use of the power saw) was slightly terrifying but all the more admirable for it (I was asking myself how much training one had to go through in order to saw off slabs of bone with such speed and confidence). First, a slice of bone from the left side of the femur was sawed off and replaced with a metal disk. After this, portions of the cartilage connecting the femur to the tibia were systemically sawed away. Throughout all of this, the surgeons continuously checked the alignment of the knee to the rest of the leg. Finally, after the damaged cartilage was removed, metal replacements for the femur and tibia’s cartilage were inserted (the doctors went through several different sizes before finding the proper ones) and held in place with bone cement. The opening was then washed with a dark fluid (I forgot to ask for its name). Overall, the procedure was surprisingly quick, lasting no more than three hours. I thanked Dr. Krosin for inviting me to watch and left the OR.

After a two month hiatus, I was excited to be back in the OR. I arrived at Highland at 7:15AM and listened in on a medical ethics talk by Dr. Harken. Though I had heard a similar talk by Dr. Harken a few months back, something really stood out to me this time around. Dr. Harken took out a pocketbook of the U.S. Bill of Rights from the inside of his coat and read the first amendment aloud. He made a point that people have the right to practice religion, but some beliefs can compromise the ability to deliver healthcare. The residents had some great input in this discussion. At what point can we breach the first amendment to ensure the safety of others? This is a topic that deserves thorough elaboration especially when it comes to vaccination. Doctors are trained for medical intervention, but the extent of intervention that doctors are entitled to is seldom clearly defined. It was great food for thought before getting my day started. Dr. Francesca Maertens was my resident guide for the day and I was happy to follow her into the OR.

CASE 1 – Fistula

Dr. Harken & Dr. Maertens

Entered OR @ 8:10AM

I asked Dr. Maertens about how she decided between surgery and medicine because I had heard that it was a major fork in the road before becoming a doctor. Dr. Maertens described how surgeons have a distinctive personality and an innate ability to be calm under even the worst circumstances. She compared the competitive personality of a surgeon to that of an athlete. The live surgery was essentially a performance, similar to a game for an athlete. My experiences so far in the OR were absolutely consistent with what Dr. Maertens had to say.

The first case of the day was a cimino fistula. I had heard the term fistula before, but I really didn’t know what its purpose was. Dr. Maertens told me to look up the procedure a few minutes before the surgery started, which was really helpful in getting myself to ask the right questions when the procedure actually began. For the large majority of cases, a fistula is a surgical manipulation to connect an artery to a vein for access to the bloodstream for dialysis patients. An ultrasound was used along the patients left arm to locate nerve for anesthetic injection. A large needle with an electrode was used to determine where the nerve was. When a voltage was applied near the nerve, the entire arm would twitch in a pulsatile, rhythmic fashion. Dr. Harken pointed out the deep veins and arteries that looked like large circles on the ultrasound screen. Veins collapsed much more easily upon applied pressure than arteries so it was easy to differentiate veins and arteries. Once the anesthesia was in place, it was time to start cutting.

Dr. Maertens made a cut parallel to the length of the arm that was about 4 ½ inches long. The cut exposed a large artery, a large vein, and a nerve. A yellow loop was tied around each tissue type. Dr. Maertens used a black marker to mark the vein in black. The vein was cut and injected with a clear, anti-clotting agent. A separate incision was made parallel to the first cut to locate an artery to attach the vein to. Once the artery was identified, a yellow loop was tied around it. The artery was carefully cut and suspended so that the vein can be threaded into the artery. Dr. Maertens knotted the artery-vein attachment and felt around the attachment to ensure that there was proper blood flow. The skin was sutured and the procedure was finished in a little over two and half hours. The patient was awake for the entire procedure and I only noticed once the surgery was completed.

CASE 2 – AV Graft

Dr. Harken and Dr. Maertens

Entered OR 10:31AM

The subsequent case was an AV graft. Despite the lack of similarity in name between an AV graft and fistula, the procedures are nearly identical. The one major difference between the two procedures was that in an AV graft, the artery and vein are joined by a white tube. The major advantage in using another material to join the artery and vein is that the white tube has a large diameter, which ensures great blood flow between the artery and the vein. This makes complete sense according to Poiseuille’s Law on blood flow. Who knew physics was important in medicine after all.

Dr. Maertens started by making two parallel incisions along the elbow bend. The median nerve was exposed and it looked like a flat elastic band. Prongs were used to hold the medial incision open. Plastic yellow ropes were tied around the nerve, artery, and vein just as had been done for the fistula case. A third perpendicular incision was made distal to the first two incisions. The vein was marked and cut. Anti-clotting agent was added to the vein and the white tube was attached to the vein. Dr. Harken explained that the white tube was made of the same material used in North Face outerwear jackets. Once the white tube was attached to the vein, it was pulled through the perpendicular incision and back inside to reach the second parallel incision. The artery was carefully cut and knotted to prevent bleeding. Dr. Maertens used a syringe to inject saline through to make sure that the passageway was not obstructed. The artery was then attached to the white tube.

The three incisions were promptly sutured and the procedure was finished by 1pm. I thanked Dr. Harken and Dr. Maertens for the great opportunity and I was on my way out of the OR just in time for my afternoon class. It was an awesome day of surgery to say the least.

My first OREX day was an absolutely terrific and most magnificent experience I have yet to experience at Highland Hospital. Though the surgeries themselves were a great spectacle, I couldn’t help but note down a lot of things that may be trivial to all those who work in the OR, but to me they were really quite interesting. In comparison to 5E and SDU, the department I have been volunteering for the past couple of months, I couldn’t help but notice how CLEAN everything was. And I mean CLEAN. Hospitals are normally thought to be clean places, there are so many sick people entering and leaving, and I know that it’s very hard to maintain a sterile environment. The operating room however, is seriously no joke. Everything was pre-packaged, everything sterile was blue, everything was systematic, and everything was carefully and preemptively thought out. I admired the environment and the precautions taken to ensure prevention of contaminations and infections that could jeopardize not just the hospital’s reputation, but human lives! The thought process that goes into designing an OR and what goes in the OR is absolutely magical to me; it takes a lot of brilliant and practical minds to prepare an environment as such. To the say the least, I’m really happy to finally know what the inside of an OR looked like.

Upon entering my first surgery observation, I reminded myself to remain very calm. Standing in the middle at least five feet away from everything, I analyzed the room and carefully made my way to an area as far away from blue so that I could get a good view of the patient without contaminating anything. Dr. Lee introduced himself to me and told me the patient had large masses developing at the site of where he received dialysis, his left forearm. This is also called a renal fistula. Dr. Lee said the masses growing maybe due to an infection and that him and Dr. Harken would be able to figure out the source of growth with this surgery. I watched Dr. Lee as he felt the masses, slightly pushing on the masses and methodically moving his way up and down the arm, even in areas where there was no lump. He told me that the vein in which the patient received dialysis felt hard. Both Dr. Harken, Dr. Lee, and Nurse Ruthie made their way to the operating table. With just an arm exposed in a sea of blue sheets placed atop the patient, they began.

Dr. Harken drew lines such that the end product looked similar to that of standing waves. Dr. Lee then used a scalpel to cut the patients skin, carefully following the lines Dr. Harken’s lines. Next, Dr. Lee used a device to separate the skin surrounding the mass, revealing an enlarged vein. I now realize the device is called a cauterizer, I thought it was kind of cool and weird to see how easily it separated skin and let off smoke… In the middle of all this, another person joined us, he turned out to be a medical student, it was his first time seeing a vein removal too!

The first piece of the vein was removed, and Dr. Harken pointed out the graft that was placed INSIDE of the vein to prevent the clot. Unfortunately for the patient, the graft did not help with that, because when the medical student squeezed the second piece of vein, a large, squishy, dark, and thick clot of blood came out. AND THAT, my fellow Orexers, was the cause of the huge growths. Prior to the removal, I should note that there were four noticeable masses lined up on the patient’s inner forearm. The largest of the masses were the middle two, the size of the masses…imagine cutting a decent size boiled egg in half, hot dog style, then placing that half on your arm. That big.

In total, three pieces of the vein were removed from the mans arm, each end of the remaining ends of the vein were stitched closed by Dr. Lee. And for those of you wondering, what happens when you remove a vein? Don’t we need it? (At least those were the thoughts running through my mind) We actually don’t need it, there are other veins in our arms, and instead of the blood running through the severed vein, they’ll just find another vein to flow through!

I attended five other surgeries afterwards, all are definitely worth talking about, but there was one particular surgery that I felt was truly unforgettable.

I was on my way to the cafeteria to grab a quick bite before heading back to one last surgery, and Dr. Krosin actually stopped me and asked if I wanted to join him on his hip replacement surgery! Of course I said I would love to! I rushed back to the OR, and tried finding my way to OR #1. Instead I found myself walking into Dr. MacDonald’s nasal polyp removal surgery. He allowed me to watch him in two other surgeries that day, and I decided that I would stay because I thoroughly enjoyed the way he talked through the surgery and gave his resident pretty helpful tips. (It still would have been awesome to see the hip replacement surgery, hopefully I have a chance to watch another time.)

The patient had severe polyp growth in his nasal cavity, to the point where he had chronic headaches and could not breath out of his nose. Before the surgery took place, a resident, Dr. Zerhouni showed me an MRI of the patient’s head. She pointed out how the nasal cavity of the patient was grey in color, and it shouldn’t be. It should instead be black in color, which represents air. The grey color denoted liquid that filled up the patient’s nasal cavity, very abnormal and is the precise reason why he was in the OR that day.

Dr. MacDonald used an endoscope,a device with a camera and light on the end, so I got to enjoy most of the surgery on a big screen. First impression was that it would be a short surgery, because Dr. MacDonald’s previous surgeries were much shorter than the other ones I experienced. The surgery ended up being over two hours long. One by one, Dr. MacDonald began removing these milky colored polyps from the patient’s right nostril, and it seemed as if these polyps were just attached via mucus-like strings. Each polyp removed was taken by Nurse Nina, and she placed them in jars to be taken down to pathology. While performing the procedure, Dr. Macdonald carefully talked through it to Dr. Zerhouni, and eventually she took a turn at removing the polyps in the left nostril. This procedure was drastically different from the vein removal, it was very microscopic and it required a lot more technological instruments. It reminds me how blessed we are to live in an era where we have so much access and knowledge to such useful instruments that are used to save and/or better human lives.

Nearing the end of the surgery, I remembered both the assisting nurse, Wendy, as well as Dr. MacDonald acknowledging how much this surgery is going to change this young man’s life. Though this was not a typical life-saving surgery, it was a one to enhance this person’s quality of life. I felt that the first surgery I attended was a lot less humanistic in comparison to the polyp removal. I’m not saying that Dr. Lee and Dr. Harken are robots, but I think the way Dr. MacDonald kept mentioning how much better off this man is going to be after this surgery is what really opened my eyes to what surgery can do aside from saving a life. Certainly anyone or anything can live, but I think that the emphasis on the quality of life is sometimes forgotten.

Overall, I find that my first day of surgery was successful, inspiring, and it’s left me craving more time in the OR.